With new treatments and better prevention, these killer headaches may soon be history

Here's a brainteaser: Migraine headaches can be (a) blamed on your parents, (b) made worse by medicine or (c) prevented by Botox. The answer: all of the above. There are other surprises in migraine research, including this: Up to 14 million people may be walking around thinking they have an ordinary headache when they really have a migraine. That means they're not getting the best treatment, including new drugs that can make even longtime sufferers headache free. What else? Read on for more news and answers to your questions.

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What Is a Migraine, Anyway?

We call it a headache, but it's a disease. During an attack, the brain stem becomes hyperactive, sparking a drop in the chemical serotonin. The result is an increase in swelling of blood vessels surrounding the brain -- and pain.

What a migraine is not: all in your head. "The myth persists that people with migraines are hypochondriacs, but in fact the condition is biological and has a strong genetic component," says Merle Diamond, M.D., associate director of the Diamond Headache Clinic, in Chicago. "If one parent has them, there's a 50 percent chance the child will. Two parents, the odds are 75 percent." (Dr. Diamond and her husband have migraines; three of their four kids do too.)

Chalk it up to confusion over what's a tension headache (it's achy but not disabling) and what's a migraine (it knocks you flat for hours, even days). Another misconception: that all migraine sufferers see a constellation of lights known as a visual aura. "Up to 80 percent have no aura," says Jan Lewis Brandes, M.D., director of the Nashville Neuroscience Group in Tennessee. (Some patients get only the aura, sometimes with just a mild headache -- a condition called migraine equivalency.) In making a diagnosis, doctors look for a specific set of symptoms (see box, below).

The SymptomsThere are many kinds of severe headaches. To meet the official diagnostic definition of a migraine, you need at least one of these:

moderate to severe pain that occurs on one or both sides of the head a throbbing or pulsating sensation worsening of the pain with activity, even routine

And at least two of these:

nausea and/or vomiting sensitivity to light sensitivity to noise

What Triggers an Episode?

Anything that affects the brain's already sensitive blood vessels -- an approaching storm, pressure changes on a plane, even an orgasm. Hormones, however, are the major culprit, which explains why women sufferers outnumber men three to one. Name anything that causes an estrogen change (menstruation, birth control pills) and you've also named a common migraine cause.

A host of other triggers may play a supporting role. Stress, coffee and alcohol are common offenders. Some patients also swear that chocolate, aged cheeses, yogurt and oranges set off their migraines, but doctors aren't entirely convinced. The only way to know what might ignite your particular sensitivity is to keep a diary and see if a pattern emerges: Record each episode and note everything you've eaten in the last six to eight hours and what you were doing when the pain came on.

Powerful prescription drugs like Imitrex or Zomig, which prevent depletion of serotonin in the brain, can provide real relief. You need to act fast: Taking medication in the first 10 or so minutes of an attack gives you the greatest chance of stopping the migraine, says Dr. Diamond.

Be careful with over-the-counter headache remedies. If they don't work, you may be inclined to pop more pills, more frequently. That can cause a rebound effect that turns occasional headaches into chronic ones.

Can You Prevent Migraines?

After a study found that the antiseizure drug Topamax dramatically cut the frequency of migraine attacks, the FDA approved it for use in migraine prevention. As for side effects, there's a curious one: weight loss. Note: The approval was in 2004.

Another surprising weapon: Botox. The same serum that "freezes" wrinkles seems to stop the muscle contractions of migraines, says Alexander Mauskop, M.D., director of the New York Headache Center, in Manhattan. The injections go wherever you feel the pain -- typically in the forehead, temples and neck. "Many patients are migraine free for three months," he says. The cost (high) is increasingly covered by insurance.

Any Nondrug Treatments?

Biofeedback, which helps you learn to relax muscles during times of stress, provides relief for some patients. So does acupuncture, according to a recent British study. And exercise can improve circulation, opening constricted veins.

Do You Need a Specialist?

Start with your regular doctor, but if you don't get enough help, try a neurologist or other physician who has a particular interest in migraines (she needn't be a specialist in the field). There are also hundreds of headache clinics, often associated with hospitals. To learn more, visit the Websites for the American Council for Headache Education (achenet.org), the American Headache Society (ahsnet.org) and the National Headache Foundation (headaches.org).